MS-DRG 207 slides

Respiratory Failure with Ventilator Support >96 Hours (MS-DRG 207)

Learn How to avoid RAC denials and file an effective appeal

1. 1
Part Three:
Top MSTop MS--DRG’s at RiskDRG’s at Risk
Documentation, Coding Audit, and Appeal Workshops
Sponsored by Intersect Healthcare, Inc.
Part Three:
Respiratory Failure with Ventilator
Support >96 hours
(MS-DRG 207)
Next Session:
Wd d Jl 7Wednesday, July 7
1:00PM EST
Chest Pain (1 day stay):
A Clinical Documentation, Coding Audit &
Appeal Workshop (MS-DRG 313)
Part Three:
Top MSTop MS--DRG’s at RiskDRG’s at Risk
Sponsored by Intersect Healthcare, Inc .
Documentation, Coding Audit, and Appeal Workshops
Part Three:
Respiratory Failure with Ventilator
Support >96 hours
(MS-DRG 207)
Your Panel:
Tracey Goessel, MD
Clinical Overview of MS-DRG 207
Charmira Johnson, CCS, BS, LPN, CCDS
The RAC and MS-DRG 207
Denise Wilson, RN, RRT, MS
Appealing a MS-DRG 207 Denial

2. 2
MS DRG 207:
Respiratory Failure with
V til t S t >96 h
Tracey Goessel, M.D.
Ventilator Support >96 hours
Tracey Goessel, M.D.
CEO
FairCode Associates
¾Inability of the lungs to perform their basic
What is “Respiratory Failure”?
ygp
task of gas exchange: the transfer of
oxygen from inhaled air into the blood and
the transfer of carbon dioxide from the
blood into exhaled air.
¾We tend to think of it as being a state ¾We tend to think of it as being a state
where the patient’s oxyg en is too low; but
it can be also a state where the CO2 is too
high.
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3. 3
¾Alveolar Hypoventilation
–Drug overdose/respiratory suppressants
–Chest wall trauma
What are the Causes of
Respiratory Failure?
Chest wall trauma
–Neurologic disorders (stroke, MS), Neuromuscular disorders
(myasthenia gravis), Muscular disorders (muscular dystrophy)
¾Capillary wall/alveolar damage
–Near drowning
–Pesticide exposure
–Smoke inhalation/fire
¾Inadequate alveolar wall surface – COPD!
¾Loss of elasticity in the lungs
–Pulmonary fibrosis
–Sarcoidosis
–~ 100 others
¾Loss of pulmonary vascular bed
–Massive pulmonary embolism
52010 Intersect Healthcare, Inc. FairCode
How Do We Diagnose Respiratory Failure
– From a Clinical and Coding Standpoint?
¾In patients without underlying disease ,
the general rule of thumb is pO2 < 60 gp
and/or the pCO2 > 50.
¾COPD patients often have baseline pO2s
that are low and pCO2s that are elevated.
ƒLook at pH: is patient acidotic, or compensated?
ƒDro
p of 10-15 points in pO2 from baselineis p pp
suggestive.
¾Patient does not need to be on
ventilator for respiratory failure to be
the diagnosis!
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4. 4
¾The use of the term “respiratory insufficiency” as a
What are the Challenges in Physician
Documentation of Respiratory Failure?
¾The use of the term “respiratory insufficiency” as a
synonym.
¾The failure to document baseline blood gases in
COPD patients
¾The hesitancy to document respiratory failure if the
patient is not on a ventilator.
72010 Intersect Healthcare, Inc. FairCode
¾BiPAP S/T-D ventilatory support system: augments
patient’s ability to breath on their own – while it is
continuous it does not qualify as “continuous
When is ventilatory support considered
Non-invasive mechanical ventilation?
continuous, it does not qualify as continuous
manual ventilation” because it is not given via
ET/NT or trach tube
¾CPAP - continuous positive airway pressure not
through ET/NT or trach tube
¾NIPPV i i iti til ti¾NIPPV -noninvasive positive pressure ventilation
¾NPPV - nonpositive pressure ventilation
¾PEEP - not given via ET/NT or trach tube
82010 Intersect Healthcare, Inc. FairCode

5. 5
¾BiPAP S/T-D ventilatory support system: augments
patient’s ability to breath on their own – while it is
continuous it does not qualify as “continuous
When is ventilatory support considered
Non-invasive mechanical ventilation?
continuous, it does not qualify as continuous
manual ventilation” because it is not given via
ET/NT or trach tube
¾CPAP - continuous positive airway pressure not
through ET/NT or trach tube
¾NIPPV i i iti til ti¾NIPPV -noninvasive positive pressure ventilation
¾NPPV - nonpositive pressure ventilation
¾PEEP - not given via ET/NT or trach tube
92010 Intersect Healthcare, Inc. FairCode
¾BiPAPthough given via ET/NT or trach tube
When is Ventilatory Support Considered
Invasive Mechanical Ventilation?
¾BiPAPthough given via ET/NT or trach tube
¾CPAP given via ET/NT or trach tube (mostly!)
¾PEEP given via ET/NT or trach tube
¾IPPV - invasive positive pressure ventilationpp
102010 Intersect Healthcare, Inc. FairCode

6. 6
¾Capturing when the post-operative period on a
ventilator counts as an “unexpected, extended
period of mechanical ventilation ”
What are the Challenges in Physician
Documentation of a Patient
Already on a Ventilator?
period of mechanical ventilation .
¾Capturing the time of intubation.
ƒAnesthesia records usually precise; ER records less so.
ƒIncision of tracheotomy/cricothyroidostomy represents moment of
intubation in surgical airways. ¾Capturing the time of extubation¾Capturing the time of extubation .
ƒOral/nasotracheal intubation: ends when tube pulled.
ƒWeaning periods count with trach patients.
ƒTube may remain indefinitely, so once pt weaned off mechanical
ventilation, that is when clock stops.
ƒRespiratory therapy notes generally more helpful and specific than
MD notes
112010 Intersect Healthcare, Inc. FairCode
¾Respiratory failure is not a symptom. It is a
diagnosis. As such, it may be coded as the principal
diagnosis even when the cause is known
What are the Challenges in Determining When to
Make Respiratory Failure Principal Diagnosis?
diagnosis, even when the cause is known .
¾For the most part, if respiratory failure is present at
admission, it trumps the underlying cause. You list
it first.
¾Chapter-specific coding guidelines may over-ride
thi lthis rule:
–Obstetrics
–Poisoning
–HIV
–Newborns
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7. 7
¾A 24-year-old female throws a massive
pulmonary embolus, re quires intubation,
Example:
and is on the ventilator for 5 days.
–If the embolus is a peri-partumpulmonary embolism,
then OB sequencing guidelines require you to list PE
first. This leads you to 781/782 Other Antepartum
Diagnoses with or without Medical Complications
–If the embolus is not obstetric in nature, then
respiratory failure may be sequenced first, leading to
MS DRG 207.
132010 Intersect Healthcare, Inc. FairCode
¾Work to get the attending to specify the
cause of the respiratory failure. If he/she
Accordingly:
documents that it is a cause outside of the
poisoning/HIV/newborn/obstetric arena,
you may code respiratory failure first.
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8. 8
When in Doubt…
¾Refer to Coding Clinics
¾Query, query, query!
152010 Intersect Healthcare, Inc. FairCode
¾Respiratory Insufficiency
–The term “respiratory insufficiency” is not specific from a coding
standpoint. The patient presented with pneumonia, cyanosis and the
following blood gases: pH 7.29/pO2 57/pCO2 49/HCO3 15. Please define
the condition that was the underlying cause of the above documented
Sample Queries
the condition that was the underlying cause of the above documented
laboratory studies.
¾Unexpected, extended period of ventilation
–The patient underwent an anterior/posterior cervical fusion. Post-
operatively, you noted “extensive anterior edema” and maintained the
patient on a ventilator for 18 hours in the ICU. In your opinion, does this
represent a normal post-operative ventilatory duration, an extended post-
operative ventilatory duration, or are you unable to determine?
¾Underlying cause of respiratory failure
–This patient presented with respiratory failure requiring mechanical
ventilation. He was documented to have consumed an overdose of Tylenol,
requiring Mucomyst administration, as well as bi-lobar aspiration
pneumonia. Please define what, in your opinion, was the underlying cause
of the respiratory failure, if known.
Copyright 2009 5 16
2010 Intersect Healthcare, Inc. FairCode

9. 9
The RAC
and
MS-DRG 207MSDRG 207
Charmira Orr BS, LPN, CCS, CPC, CCDSCa a OS,,CCS,CC,CC S
Intersect Healthcare, Inc.
Learning Objectives
¾T Ud t d H t U P t Fidi ¾To Understand How to Use Past Findings
of the RAC Demonstration Area to Help
Tell Your Coding Validation Story
¾To Understand How to Break Down the
Guidelines to Abstract Data from the
Medical RecordMedical Record
¾To Understand How to Tell Your Coding
Validation Story
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10. 10
The RAC Demonstration
‰Wrong Principal Diagnosis-RACs found that the ‰Wrong Principal DiagnosisRACs found that the
principal diagnoses on claims did not match the
principal diagnoses in the medical record. For
example, respiratory failure (code 518.81) was listed
as the principal diagnosis, but the medical record
indicated other conditions such as sepsis (code
038.0–038.9) was the principal diagnosis.
‰In 2007 42% of the recoupment s were directly
tt ib t d t i t diattributed to incorrect coding
‰In NY $ 9.5 Million collected, CA $ 4.1 million
collected, FL $1.7 Million collected.
192010 Intersect Healthcare, Inc.
Connolly Healthcare ©2010
¾Issue Name: Respiratory System Diag nosis with Ventilator Support 96+
Hours: MS-DRG 207 (At this time, Medical Necessity excluded from review).
¾Description:DRG Validation requires that diagnostic and procedural information
and the DRG Validation requires that diagnostic and procedural information and
the discharge status of the beneficiary, as coded and reported by the hospital on
its claim, matches both the attending physician description and the information
contained in the beneficiary's medical record. Reviewers will validate for MS DRG
207, previously DRG 565, principal diagnosis, secondary diagnosis, and
procedures affecting or potentially affecting the DRG.
¾Provider Type Affected: Inpatient Hospital
¾Date of Service: 10/01/2007 -Open States Affected: Alabama, Arkansas,
Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina,
Oklahoma, South Carolina, Tennessee, Texas, Virginia (WPS only), West Virginia
(WPS only) Additional Information: Additional information can be found on the
following manuals/publications:
¾ICD-9-CM for Hospitals Vol. 1, 2 & 3, Coding Guidelines, Section II, A, B, C, D, E,
F, G , H
¾ICD-9-CM Addendums and Coding Clinics
¾PIM Ch. 6.5.3, Section A-C DRG Validation Review
202010 Intersect Healthcare, Inc.

11. 11
Respiratory System Diagnosis with Ventilator
Support >96 Hours (MS-DRG 207)
MDC4 GMLOS/RW AND
•Medical‐
Any 
Principal 
Diagnosis 
inMDC4
•GMLOS‐
12.8
•RW 5.1055 
•Transfer 
DRG
•Non Operating 
Room 
Procedures
• ICD‐9 CM 96.72‐
Continuous 
invasive 
mechanicalin MDC 4 DRG mechanical 
ventilation for 
96 consecutive 
hours or more
212010 Intersect Healthcare, Inc.
Understanding the Guidelines
‰The Uniform Hospital Disc harge Data Set ( UHDDS)
defines the principal diagnosis as the condition defines the principal diagnosis as the condition
established after study and is the primary reason
responsible for the admission of the patient to the acute
care setting within the hospital. In accordance to coding
guidelines the reason and circumstances that led to the
inpatient admission must take precedence as the
primary diagnosis.
- ICD- 9 codes Various respiratory Conditions
throughout the Index
AND
‰Mechanical Ventilation- Located under ICD-9 code 96.7
Includes: BiPAP delivered through endotracheal tube or tracheostomy (invasive interface)
CPAP delivered through endotracheal tube or tracheostomy (invasive interface)
Endotracheal respiratory assistance, Invasive positive pressure ventilation [IPPV]
Mechanical ventilation through invasive interface That by tracheostomy
Weaning of an intubated (endotracheal tube) patient
Excludes:Noninvasive ventilation like face mask, nasal cannulas, nasal catheters
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12. 12
Mechanical Ventilation –ICD-9
96.7 Guidelines Cont’d
Endotracheal Intubation
To calculate the number of hours (duration) of continuous mechanical ventilation during a
hospitalization, begin the count from the start of the (endotracheal) intubation. The
duration ends with (endotracheal) extubationduration ends with (endotracheal) extubation.
If a patient is intubated prior to admission, begin counting the duration from the time of
the admission. If a patient is transferred (discharged) while intubated, the duration would
end at the time of transfer (discharge).
For patients who begin on (endotracheal) intubation and subsequently have a
tracheostomy performed for mechanical ventilation, the duration begins with the
(endotracheal) intubation and ends when the mechanical ventilation is turned off (after
the weaning period).
Tracheostomy
To calculate the number of hours of continuous mechanical ventilation during a
hospitalization, begin counting the duration when mechanical ventilation is started. The
duration ends when the mechanical ventilator is turned off (after the weaning period).
If a patient has received a tracheostomy prior to admission and is on mechanical
ventilation at the time of admission, begin counting the duration from the time of
admission. If a patient is transferred (discharged) while still on mechanical ventilation via
tracheostomy, the duration would end at the time of the transfer (discharge).
Please Note Must code in addition If performed:
endotracheal tube insertion (96.04)
tracheostomy (31.1-31.29
232010 Intersect Healthcare, Inc.
Auditing to tell the Story
Examine
ReviewQuery
Documentation
Review
Abstract
Track
Data
Query
Code
Compare
Identify

13. 13
Process Steps to Auditing the
Medical Record
1. Examine - The medical record to ensure
that it is a complete record. Physician py
attestation statement and Discharge
Summary is on the record, as well as nurses
notes, treatment records and etc..
2. Review
- Must review the Entire Medical
Record to accurately assign the principal and
secondary diagnosis
3. Abstract- Data from the Medical Record
a. Abstraction Worksheet
252010 Intersect Healthcare, Inc.
Abstraction Worksheet
1. Is there an inpatient admission order for the initial date of service? Yes/No
2. What are the documented reasons for admitting the patient to inpatient care?
3. On the attestation statement is there a change in the working diagnosis to the principal diagnosis? Yes/No
4. What is the principal diagnosis billed on the claim?
5. Is this the same principal diagnosis assigned to the medical record? Yes/No
6. Was the patient transferred from another acute care facility on mechanical ventilation? Yes/No

7. Length of stay: ____________________ 8. What is the documented diagnosis for patient to be on mechanical ventilation? 9. Is there any laboratory values to support? ABG’s Yes/No
10. Discharge Status
‰Home or Self Care -01
‰Discharged/ Transferred to a Short Term General Hospital for Inpatient Care -02
‰Discharged/ Transferred to a SNF with Medicare Certification in Anticipation of killed Care - 03
‰Discharged/Transferred to an Intermediate Care Facility -04g/ y
‰Discharged/Transferred to Another Type of Health Care Facility Not elsewhere in the Code List- 05
‰Discharged/ Transferred to Home Care- 06
‰AMA -07
‰Expired-20
11. Where there any test that revealed any Malignant conditions? Yes/No
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14. 14
Abstraction Worksheet Cont’d
12. Was treatment during stay directed at the Malignant conditions? Yes orNo
13. Were there any complications noted during stay?
Yes or No
14. Date and time if applicable of endotracheal intubation or tracheostomy for ventilation:
________________________________________________________
Was this patient transferred to this institution on mechanical ventilation? Yes or No
Was patient discharged or transferred while intubated: _____________________
If applicable date and time patient was extubated:_________________________
Was ET or Tracheostomy performed in inpatient status? ____________________
Date and time mechanical ventilation was initiated? _______________________
Was patient weaned during time on the vent? If so hours___________________
Date and time mechanical ventilation ended:_____________________________
Was the patient completely weaned off the vent, and restarted within any time frame during the same
admission? Yes or No, If applicable list dates______________________
15. Is there any evidence in the medical record that the patient was only intubated for a procedure? Yes/No
16. Is there any evidence in the medical record that the ventilation is due to postoperative complications? 17. Was the patient diagnosed with any type of Respiratory Failure? Yes/No
If so; Date and time and list any applicable testing that led to diagnosis
__________________________________
18. Was the patient admitted with Respiratory failure or did it develop after admission? Yes/No
272010 Intersect Healthcare, Inc.
Process Steps to Auditing the
Medical Record
4. Code- Reviewer will code from data that they abstracted
5. Compare - Codes they assign to the codes that were
billedbilled
6. Identify- Any areas in the medical record for areas of
uncertainty and discrepancies
7. Track Data Collected
- Highlight areas, photocopy
areas in question to possibly highlight for physician
8. Query
- The provider on any discrepancies found. Send
them the highlighted portions of the medical record so gg p
that they can view. DO not lead .. Only identify what is in
the record and ask for clarification
a. Statement of Issue or Discrepancy
b. Date Initiated
c. Contact person and Info
d. Date Query Completed
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15. 15
The Story
Principal Diagnosis Documentation to support Secondary Diagnosis Procedures MS-DRG
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Learning Objectives
¾Ensure there is documentation in the medical record to
support assigning a principal diagnosis within MDC 4support assigning a principal diagnosis within MDC 4
¾Ensure that there is a definitive diagnosis that affects or
will affect the respiratory system to initiate – INVASIVE
MECHANICAL VENTILATION (i.e. surgery, respiratory
failure, and etc.)
¾B bl t t k th ti th t h i l til ti i ¾Be able to track the time that mechanical ventilation is
initiated to the time that it ends within the institution
¾Know the difference between Invasive and Non-Invasive
Ventilation
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16. 16
Coding Clinics
Intubation / Mechanical Ventilation Intubation / Mechanical Ventilation
/Respiratory Failure
Absence of intubation and mechanical ventilation does not
preclude the use of a diagnosis of respiratory failure, 518.8x.
(See Coding Clinic, third quarter 1988, page 7.)
Respirator Dependence
Code 46.1, other dependence of machines, respirator, was expanded 10/1/2004 Code46 11 dependence on respirator expanded 10/1/2004. Code46.11, dependence on respirator,
status, is only used if there are no complications or malfunctions of respirator and is always a secondary code. Code 46.12, encounter for respirator dependence during power failure, can only be a principal or first-listed code. (DRG 467)
(See Coding Clinic, fourth quarter 2004, pages 100 and 101.)
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Coding Clinics
Sequencing of respiratory failure in association with Sequencing of respiratory failure in association with
respiratory conditions.
The sequencing depends on the reason for admission. When
respiratory failure due to an underlying respiratory condition is the
reason for the admission, the respiratory failure is the principal
diagnosis. When the respiratory failure develops after admission, it is
a secondary diagnosis. When a patient is admitted due to respiratory
failure and pneumonia, the respiratory failure is sequenced first. These
conditions are not co-equal. The guideline regarding two or more
interrelated conditions meeting thedefinition of principal diagnosis
does not apply, since this has been specifically addressed in separate
Codin
gClinic instructions.g
(See Coding Clinic, first quarter 2005, pages 3-8, and Coding
Clinic, second quarter 2003, pages 21 and 22; Coding Clinic, second
quarter 2000, page 21; Coding Clinic, second quarter 1991, pages 3-5;
and Coding Clinic, November- December 1987, pages 5 and 6.)
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17. 17
References
HTTP://LIBRARY.AHIMA.ORG/XPEDIO/GROUPS/PUBLIC/DOCUMENTS/AHIMA/BOK1_043474.HCSP?D
DOCNAME=BOK1_043474
HTTP://WWW.COMPLIANCECONCEPTS.COM/PRESSROOM/UNCOVERINGTHEMYSTERYBEHINDTHERA
CCOMPLEXCODINGREVIEWS.ASP
HTTP://WWW.PEPPERRESOURCES.ORG/LINKCLICK.ASPX?FILETICKET=RK7HAMWQYTU%3D&TABID=7
5&MID=416
332010 Intersect Healthcare, Inc.
Appealing a Respiratory
System Diagnosis
w/ Ventilator Support Denial
Denise Wilson RRT, RN, MIS
Director, Client Education 
andPerformanceImprovementand Performance Improvement
Intersect Healthcare, Inc.

18. 18
Learning Objectives
•Understand how to create a successful
coding or medical necessity appeal for coding or medical necessity appeal for
Respiratory System Diagnoses by:
–Understanding the issue at hand
–Providing a ‘Road Map’ for the reviewer
–Presenting a Preponderance of Evidence
•(Best Practice, Regulatory and CMS Guidelines)
•Understand how to tailor appeals to
the Administrative Law Judge
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Understanding the Issue at Hand
¾OIG Report on DRG 475 released December 
1998
–(DRG 475 is now MS‐DRG 207, 208)
¾DRG 475 was top 5% of DRGs in terms of relativeweightrelative weight
–http://oig.hhs.gov/oei/reports/oei‐03‐98‐
00560.pdf
2010 Intersect Healthcare, Inc. 36

19. 19
Understanding the Issue at Hand
¾In 1996, it was estimated that 7% of DRG 475 
shouldhavebeencodedtoalowerweightDRGshould have been coded to a lower weight DRG
¾In 1996,  Approximately $10,000 difference per 
case, or $11.5 million
¾DRG 475 vs. DRG 127 Heart Failure and Shock
¾High Relative Weight and vulnerable to upcoding
2010 Intersect Healthcare, Inc. 37
Trending DRG Discharges
Department of Health and 
Human Services, Office of 
Inspector General, 
Medicare Payments for 
DRG 475
Respiratory System 
Diagnosis with Ventilator 
Support, December 1998
OEI‐03‐98‐00560 
http://oig.hhs.gov/oei
/reports/oei-03-98-
00560.pdf
2010 Intersect Healthcare, Inc. 38

20. 20
¾Considerations for Deciding to Appeal
Cost
Planning for Appeals
First Things First Planning
–Cost
–Time
–Resources
–Chance of Overturn
–Return on Investment
¾In addition to:¾In addition to:
–Root Cause Analysis
–Education/Remediation Plan
2010 Intersect Healthcare, Inc. 39
¾Close examination of decision letter
Building the Foundation
–What are the instructions for appeal?
–What forms do I need?
–Where do I send my appeal?
–What was the issue?
¾Create Appeal Letter Templates¾Create Appeal Letter Templates
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21. 21
Building the Foundation
Copyright 2009 5 412010 Intersect Healthcare, Inc.
http://racb.cgi.com/Issues.aspx
¾Paint the Picture
–Comorbidities and Complications (CC or MCC)
Creating the Structure
Comorbidities and Complications (CC or MCC)
–Medical Complexity
¾Provide a Road Map
–Where is the Documentation?
¾Write to the ALJ¾Write to the ALJ
–Best chance of overturn
¾Provide a Preponderance of Evidence
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22. 22
¾Use the Best Evidence
–CMS Internet Only Manuals (IOM)
Creating the Structure
First Things First Planning
–National Coverage Determinations; Local
Coverage Determinations
–ICD-9-CM Official Coding Guidelines
–Coding Clinics
–Code of Federal Regulations (CFR)
Social Security Act–Social Security Act
–Evidence Based Guidelines, Position Statements,
Expert Opinions from National Medical
Associations
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Providing a Road Map
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23. 23
Providing a Road Map
http://www.ama‐
assn.org/ama1/pub/upload
/mm/362/icd9cm coding g/mm/362/icd9cm_coding_g
uidelines_08_09_full.pdf
2010 Intersect Healthcare, Inc. 45
Providing a Road Map
ICD-9-CM TABULAR LIST OF PROCEDURES (FY10)
96.7 Other continuous invasive mechanical ventilation
Includes: BiPAP delivered through endotracheal tube or tracheostomy (invasive interface)…
Excludes: noninvasive bilevel positive airway pressure [BiPAP] (93 90)Excludes: non-invasive bi-level positive airway pressure [BiPAP] (93.90)….
Note: Endotracheal Intubation
To calculate the number of hours (duration) of continuous mechanical ventilation during a
hospitalization, begin the count from the start of the (endotracheal) intubation. The
duration ends with (endotracheal) extubation.
Tra c h e o s t o m y
To calculate the number of hours of continuous mechanical ventilation during a
hospitalization, begin counting the duration when mechanical ventilation is started. The
duration ends when the mechanical ventilator is turned off (after the weaning period).
96.70 Continuous invasive mechanical ventilation of unspecified duration
Invasive mechanical ventilation NOS
96.71 Continuous invasive mechanical ventilation for less than 96 consecutive hours
96.72 Continuous invasive mechanical ventilation for 96 consecutive hours or more
2010 Intersect Healthcare, Inc. 46

24. 24
Providing a Road Map
2010 Intersect Healthcare, Inc. 47
Providing a Road Map
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25. 25
•Indications for Mechanical Ventilation
–http://www.merck.com
Indications: There are numerous indications for endotracheal
Preponderance of Evidence
–Indications: There are numerous indications for endotracheal
intubation and mechanical ventilation but, in general, mechanical
ventilation should be considered when there are clinical or
laboratory signs that the patient cannot maintain an airway or
adequate oxygenation or ventilation. Concerning findings include
respiratory rate > 30/min, inability to maintain arterial O
2
saturation > 90% with fractional inspired O
2(Fio
2) > 0.60, and
PaCO
2of > 50 mm Hg with pH < 7.25. The decision to initiate
mechanical ventilation should be based on clinical judgment that
Copyright 2009 17
mechanical ventilation should be based on clinical judgment that
considers the entire clinical situation and should not be delayed until the patient is in extremis.
•Last full review/revision August 2007 by Brian K. Gehlbach, MD; Jesse Hall, MD
•Content last modified August 2007
492010 Intersect Healthcare, Inc.
¾Guidelines on the Management of
Community-Acquired Pneumonia in Adults
–Time to First Antibiotic Dose
Preponderance of Evidence
Time to First Antibiotic Dose
•For patients admitted through the emergency department (ED), the first
antibiotic dose should be administered while still in the ED. (Moderate
recommendation; level III evidence)
–Switch from Intravenous to Oral Therapy
•Patients should be switched from intravenous to oral therapy when they are
hemodynamically stable and improving clinically, are able to ingest
medications, and have a normally functioning gastrointestinal tract. (Strong
recommendation; level II evidence)
–Duration of Antibiotic Therapy
•Patients with CAP should be treated for a minimum of 5 days (level I
evidence), should be afebrile for 48 to 72 h, and should have no more than
1 CAP i d i f li i l i bili ( T bl b l ) b f
Copyright 2009 17
1 CAP-associated sign of clinical instability (see Table below) before
discontinuation of therapy. (level II evidence) (Moderate
recommendation)
Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community‐acquired 
pneumonia in adults.
Mandell LA, et.al; Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community‐
acquired pneumonia in adults. Clin Infect Dis 2007 Mar 1;44 Suppl 2:S27‐72. [335 references] PubMedhttp://www.guidelines.gov
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26. 26
¾Use guidelines in place at the time care was provided
Capping the Issue
First Things First Planning
¾Include an Attachments List
¾Include all Attachments
ƒElectronic Copy
¾Use a Document Editor to Highlight the Medical
RecordRecord
¾Send all Communication via a Traceable Method
512010 Intersect Healthcare, Inc.